The influence of age on quality of life after upper body burn.

BACKGROUND: In Spain, the number of aged persons is increasing. By the year 2066, it is expected that 34.6% of the Spanish population will be over 65 years of age. Elderly people present a higher burning risk owing in part to impaired balance and decreased physical strength, lower cognitive abilities, or socioeconomic context. OBJECTIVE: Burns to the upper body body are common and affect both emotional state and physical function, thus leading to reduced quality of life (QoL). Our objective was to determine the influence of age on the QoL of patients who experienced burns to the upper body, with burns with 2 years. METHODS: This is an observational study with a sample of 58 patients with burns only on the upper body. Patients were divided into two groups: 29 patients of age over 65 years and 29 patients under 65 years; all of them attended the Vall d'Hebron Burn Center, Barcelona, between 2011 and 2014. From the original sample, 45 patients had survived by the time the information was gathered. The QoL of these individuals was evaluated with the Spanish version of the Burn Specific Health Scale. Demographic data (sex, age, total burn surface area [TBSA], burn mechanism, pathological history, length of hospital stay, and rehabilitation duration) were collected. Statistical analysis included parametric and nonparametric tests as appropriate with R3.3.3. RESULTS: There were no differences between groups regarding the mechanism of burn, TBSA, length of hospital stay, and the domains of QoL test. High blood pressure, diabetes, and other comorbidities were significantly more common in the elderly group than in the younger group. Eleven patients died in the elderly group and two in the younger group (p=0.012). CONCLUSION: As opposed to what could be expected, in this study, there were no significant differences between surviving patients in both age groups in terms of perceived QoL. Nevertheless, mortality after a burn in the upper side of the body was significantly higher in elderly people than in younger people. The present study results do not support the use of different rehabilitation approaches in elderly patients.

Comparison of outcomes between hip fracture patients with concurrent upper limb injuries and patients with an isolated hip fracture.

BACKGROUND: Concurrent upper limb injuries can occur with hip fractures, and its incidence and effect on outcomes are unclear. The objective of this study was to review the number and types of upper limb injuries sustained by patients with hip fractures, and investigate how acute hospital stay, rehabilitation and patient outcomes are affected. METHODS: A retrospective study was performed on 820 patients with traumatic fracture of the hip over the age of 50. We reviewed the patients with concurrent upper limb injuries and compared patient outcomes - including mortality, acute length of stay in the orthopaedic ward, rehabilitation outcomes and rehabilitation length of stay. RESULTS: Thirty-four patients (4.1%) with a hip fracture had a concurrent upper limb injury. Patients with and without concurrent upper limb injuries had similar acute length of stays on the orthopaedic ward (mean 5.2 versus 5.5 days, P = 0.4), and no significant difference in mortality rates at time of discharge (0% versus 3.8%, P = 0.4) and at 30 days (2.9% versus 9.1%, P = 0.2). However, they also required significantly longer rehabilitation (mean 34.6 versus 19.9 days, P = 0.009) even after other demographic factors including upper limb injury, older age and dementia were taken into consideration (multivariate linear model: concurrent upper limb injury, P = 0.0003; older age, P = 0.05; dementia, P = 0.09). CONCLUSION: A concurrent upper limb injury is infrequent in the hip fracture population. Overall, these patients were previously higher functioning than the average hip fracture patient and required longer stays in inpatient rehabilitation than patients with isolated hip fractures.

Contemporary management of subclavian and axillary artery injuries-A Western Trauma Association multicenter review.

BACKGROUND: Subclavian and axillary artery injuries are uncommon. In addition to many open vascular repairs, endovascular techniques are used for definitive repair or vascular control of these anatomically challenging injuries. The aim of this study was to determine the relative roles of endovascular and open techniques in the management of subclavian and axillary artery injuries comparing hospital outcomes, and long-term limb viability. METHODS: A multicenter, retrospective review of patients with subclavian or axillary artery injuries from January 1, 2004, to December 31, 2014, was completed at 11 participating Western Trauma Association institutions. Statistical analysis included χ, t-tests, and Cochran-Armitage trend tests. A p value less than 0.05 was significant. RESULTS: Two hundred twenty-three patients were included; mean age was 36 years, 84% were men. An increase in computed tomography angiography and decrease in conventional angiography was observed over time (p = 0.018). There were 120 subclavian and 119 axillary artery injuries. Procedure type was associated with injury grade (p < 0.001). Open operations were performed in 135 (61%) patients, including 93% of greater than 50% circumference lacerations and 83% of vessel transections. Endovascular repairs were performed in 38 (17%) patients; most frequently for pseudoaneurysms. Fourteen (6%) patients underwent a hybrid procedure. Use of endovascular versus open procedures did not increase over the duration of the study (p = 0.248). In-hospital mortality rate was 10%. Graft or stent thrombosis occurred in 7% and graft or stent infection occurred in 3% of patients. Mean follow-up was 1.6 ± 2.4 years (n = 150). Limb salvage was achieved in 216 (97%) patients. CONCLUSION: The management of subclavian and axillary artery injuries still requires a wide variety of open exposures and procedures, especially for the control of active hemorrhage from more than 50% vessel lacerations and transections. Endovascular repairs were used most often for pseudoaneurysms. Low early complication rates and limb salvage rates of 97% were observed after open and endovascular repairs. LEVEL OF EVIDENCE: Prognostic/epidemiologic, level IV.

The correlation between stabbing-related upper extremity wounds and survival of stabbing victims with abdominal and thoracic injuries.

BACKGROUND: When treating patients with stab injuries of the torso, clinicians often lack timely information about the degree and nature of internal organ damage. An externally observable sign significantly associated with characteristics of torso injuries may therefore be useful for practitioners. One such potential sign is the presence of wounds to the hands, sometimes sustained during victims' attempt to defend themselves during the violent altercation. Thus, the primary aim of this study was to evaluate the association between presence of upper extremity wounds and the severity of the thoracic and intra-abdominal injuries due to stabbing. METHODS: This study was carried out retrospectively using data on 8714 patients with stabbing-related injuries from 19 trauma centers that participated in the Israeli National Trauma Registry (INTR) between January 1st1997 and December 31st 2013. Patients with wounds of upper extremities in addition to torso injuries (UE group) were compared to other patients with torso injuries (TO group) in terms of demographics, injury characteristics and clinical outcome. RESULTS: The compared groups were found to be homogeneous in terms of age and systolic blood pressure; the number of sustained torso injuries was also identical. The UE group comprised a slightly greater percentage of females, however both groups were predominantly male. Patients with upper extremity injuries had a lower proportion of internal organ damage (36% vs. 38.5%) and lower mortality (0.9% vs. 2%). The higher mortality of patients without upper extremity wounds remained significantly different even when adjusted by other epidemiological parameters (OR 2.46, 95% CI 1.33-5.08).The number of sustained upper extremity injuries was positively associated with deeper penetration of the torso by the stabbing instrument. CONCLUSIONS: Patients with stabbing-related upper extremity wounds had a significant survival advantage over patients without such injuries. However, a greater number of sustained upper extremity wounds may be an external sign of greater severity of thoracic and intraabdominal stabbing injuries.

Significance of Traumatic Macroamputation in Severely Injured Patients: An Analysis of the Traumaregister DGU®.

Treatment of patients with traumatic macroamputations is challenging. The aim of this study is to analyze the significance of this type of injury in TraumaRegister DGU® (TR-DGU) and to depict the rate of formal surgical ablation of the traumatically induced amputation, epidemiologic data, as well as outcome in severely injured patients with amputations. We acquired data from the TR-DGU of the German Trauma Society (DGU). The inclusion criteria for our study were Injury Severity Score (ISS) greater than 9, macroamputation, and available data about the Abbreviated Injury Scale (AIS) code. A total of 48,908 of 67,425 patients had an ISS greater than 9 and available data about the AIS code. In total, 926 (1.9%) of 48,908 patients had an immediate traumatic macroamputation on-scene. Thereof, 298 patients (32.2%) had a macroamputation of the arms, 605 patients (65.3%) had an amputation of the legs, and 23 patients (2.5%) had both. Among them, 457 patients (49.4%) with a macroamputation had monotrauma. In total, 126 patients (13.6%) underwent replantation and 800 patients (86.4%) underwent formal surgical ablation of the traumatically induced amputation. Seventy-six (23.7%) of 321 patients with upper-extremity amputations and 53 (8.4%) of 628 patients with lower-extremity amputations underwent replantation. Mortality in patients with replantation was lower (5.6% vs. 19.6%, P < 0.001). Standardized mortality rate was lower for patients with replantation (0.71, 95% confidence interval, 0.20-1.21 vs. 0.94, 95% confidence interval, 0.80-1.10; P = 0.26). Glasgow Outcome Scale (GOS) was significantly better for patients with replantation (34.0%; GOS score 5) as compared with patients without replantation (20.7%; GOS score 5; P < 0.001). In borderline patients (defined according to the orthopedic damage control principles), 91.5% received formal surgical ablation of the traumatically induced amputation and 8.5% underwent replantation. The rate of formal surgical ablation of the traumatically induced amputation is higher when principles of damage control surgery are applied. The replantation rate in the upper extremity is higher than in the lower extremity. The less ISS and base excess and the higher blood pressure, hemoglobin value, and thromboplastin time are, the safer the decision for replantation seems to be.

Compliance with recommended care at trauma centers: association with patient outcomes.

BACKGROUND: State health departments and the American College of Surgeons focus on the availability of optimal resources to designate hospitals as trauma centers, with little emphasis on actual delivery of care. There is no systematic information on clinical practices at designated trauma centers. The objective of this study was to measure compliance with 22 commonly recommended clinical practices at trauma centers and its association with in-hospital mortality. STUDY DESIGN: This retrospective observational study was conducted at 5 Level I trauma centers across the country. Participants were adult patients with moderate to severe injuries (n = 3,867). The association between compliance with 22 commonly recommended clinical practices and in-hospital mortality was measured after adjusting for patient demographics and injuries and their severity. RESULTS: Compliance with individual clinical practices ranged from as low as 12% to as high as 94%. After adjusting for patient demographics and injury severity, each 10% increase in compliance with recommended care was associated with a 14% reduction in the risk of death. Patients who received all recommended care were 58% less likely to die (odds ratio = 0.42; 95% CI, 0.28-0.62) compared with those who did not. CONCLUSIONS: Compliance with commonly recommended clinical practices remains suboptimal at designated trauma centers. Improved adoption of these practices can reduce mortality.

The use of Integra® Dermal Regeneration Template in the reconstruction of traumatic degloving injuries.

Traumatic soft tissue, or "degloving" injuries from trauma are common. These injuries are a result of shearing and disrupt tissue planes, such as the junction between muscle and bone. Traditional repair involves debridement followed by skin grafting or flap reconstruction. Many degloving injuries, however, extend to bone or tendon and the decreased vascularity of the wound bed can compromise the success of traditional repairs. Additionally, medical comorbidities make some patients poor candidates for flap reconstruction. The purpose of this study was to evaluate the success of a dermal regeneration template in the treatment of complex traumatic degloving injuries at an American College of Surgeons verified Level 1 Trauma Center. A retrospective review was conducted on all patients sustaining traumatic degloving injuries from January 2009 to July 2010, who were treated with Integra Dermal Regeneration Template followed by split-thickness autografting. Medical records were reviewed and patient demographics, injury characteristics, comorbidities, hospital course, and outcomes were summarized. Ten patients were studied. All had traumatic degloving injuries of an extremity ranging from 50 to 1000 cm. Nine had injuries extending to bone and/or tendon. After debridement, patients underwent placement of Integra followed by a split-thickness skin graft. Of the 10 patients nine had complete take of their grafts with excellent cosmetic and functional results. Degloving injuries are common in trauma. These injuries often extend to tendon and bone, which poses challenges to repair because of decreased vascularity. Placement of a dermal regeneration template followed by a split-thickness autograft is a viable alternative to traditional methods of repair.

Indications and complications of major limb amputations in Kano, Nigeria.

OBJECTIVES: To determine the indications and complications of major limb amputations in a Nigerian hospital. DESIGN: A five-year retrospective descriptive study. SETTING: National Orthopaedic Hospital, Dala, Kano, Nigeria. PARTICIPANTS: Patients who had amputations above the wrist or ankle between January 2006 and December 2010. MAIN OUTCOME MEASURES: Indications, complications and mortality. RESULTS: There were 132 unilateral amputations. The patients were mostly males and below the age of 40. Lower limb amputations (74.2%) exceeded upper limb amputations (25.8%). The commonest indication was trauma (42.4%) followed by TBS gangrene (31.8%) and malignant tumours (12.9%). Wound infection, the commonest complication, occurred in patients who had identifiable predisposing factors. The 3 deaths that occurred were in patients who had had traditional bone setter intervention: 2 were due to septicaemia; 1, due to severe tetanus. CONCLUSION: Trauma and traditional bone setter gangrene were the commonest indications. Most of the amputations were avoidable. Institution of preventive measures is imperative. Paying attention to predisposing factors can reduce complications.

Repair of arterial injury after blunt trauma in the upper extremity - immediate and long-term outcome.

OBJECTIVE: In contrast to upper extremity stab and gunshot wounds, data on management and outcome in blunt trauma (BT) are limited by small numbers and short follow-up periods. METHODS: This study is a retrospective data analysis. All patients who had undergone arterial repair after upper-limb BT were included. Exclusion criteria were artery ligation and/or primary limb amputation. Endpoints included the following: peri-operative death, limb salvage, primary and secondary patency, vascular re-operation and/or intervention. RESULTS: Eighty-nine patients (71 male; median age: 34.6 years, range: 2.5-81.7) underwent reconstruction of 96 arteries after BT since 1989: subclavian (n=16), axillary (n=22), brachial (n=48) and forearm (n=10). Concomitant arm vein lesions were present in 15 patients (17%) and accompanying nerve (n=38; 43%) and/or orthopaedic injuries (n=64; 72%) in 77 patients (87%). The 30-day mortality rate was 2% with the limb-salvage rate being 98%. Six reconstructions occluded during the first week (primary/secondary patency rate: 93%/99%). After a median follow-up time of 5.1 years, 67% of the patients were followed: There were no secondary amputations and no arterial re-interventions. CONCLUSIONS: Arterial repair in upper extremity BT has excellent early and long-term outcome. In contrast to a significant risk of early occlusion, limb loss after repair, late vascular re-intervention and late arterial occlusion or stenosis are rare.

[Surgical treatment of high-voltage electrical injuries]. / Die chirurgische Behandlung von Hochspannungsverletzungen.

PURPOSE/BACKGROUND: High-voltage burns represent a challenging surgical entity. Compared to conventional burns, these injuries are characterized by an increased morbidity and worse potential for rehabilitation. The aim of the present study was to analyse the management of high-voltage injuries during the early posttraumatic period with special emphasis on the surgical procedures. PATIENTS/MATERIAL AND METHOD: We retrospectively evaluated the medical records of patients with electrical injuries treated from 1995 - 2007. A total of 61 patients (57 men, 4 females, mean age: 34 +/- 13 years) with high-voltage burns was included for analysis. RESULTS: The majority of high-voltage burns was work-related (75 %). The mean total burn area was 35 % of the total body surface, with a mean of 29 % deep burns. An average of 4.8 +/- 4 operations were performed per patient (range: 1 - 23 operations). Surgical procedures included repeated debridement/necrectomy (100 % of all patients), early escharotomy/fasciotomy (47.5 %), and amputations (18 %). 14 patients (23 %) underwent reconstructive surgery using either local or free flaps. The mortality rate was 15 %. CONCLUSION: The surgical management of high-voltage burns is characterised by repetitive debridements and necrectomies. Despite an aggressive approach to remove necrotic tissue, the mortality in this type of injury is considerably high. Limb salvage may be achieved with the use of free microvascular flaps. However, an amputation of necrotic extremities must be considered in the copresence of septic complications.

Pattern of extremity gunshot injuries seen in Lagos University Teaching Hospital, Lagos, Nigeria.

BACKGROUND: The rising incidence of gunshot injuries (GSI) remains one of the leading causes of death, long hospitalization and economic losses worldwide. This study was undertaken due to rising incidence of civilian GSI in Lagos, Nigeria. OBJECTIVE: To determine the epidemiological characteristics of extremity gunshot injuries in Lagos, Nigeria. METHODS: This three year crossectional study of extremity gunshot injuries was conducted at the Lagos University Teaching Hospital (LUTH), Lagos, Nigeria between 1st January 2000 and 31st December 2002. RESULTS: Two hundred and fifty four patients with extremity gunshot injuries presented with 240 analyzed. Those brought in dead (BID) were excluded from the study. Ninety-five percent of the patients were males. One hundred and twenty six patients (52.5%) were in the 21-40 years age group. The patients were shot mainly (75%) at night and mostly (80%) by armed robbers. Shot guns were used in shooting 47.5% of patients. CONCLUSION: The study showed that young adult males were more affected by GSI. Most of the shootings occurred at night by armed robbers.

Comparison of real world side impact/rollover collisions with and without thorax airbag/head protection system: a first field experience study.

After the introduction of the Thorax Airbag (TA) and the Head Protection System (HPS) by BMW there has been a significant reduction of injuries in real-world collisions. Comparison of similar collisions (in-depth collision analyses) of vehicles with and without HPS/TA indicates that the effectiveness of the system was credible. Minor injuries (AIS 1) increase while serious injuries (AIS 3+) are reduced. Based on the limited cases available, a proper statistical sampling could not be achieved at this time, however the results are to be understood as indicative of a trend.

The effect of early versus late fasciotomy in the management of extremity trauma.

BACKGROUND: Recent reports have demonstrated an increase in the number of complications associated with delayed timing of fasciotomy for trauma. This study examines the effectiveness of early (less than 12 hours) versus late (more than 12 hours) fasciotomy in the injured extremity. METHODS: This is a retrospective review of 88 patients undergoing fasciotomy for extremity trauma admitted to the University of Cincinnati from January 1990 through December 1995. Records were reviewed for demographics, compartment pressures, time and type of fasciotomy, complications, limb salvage, and mortality. Statistical analysis was determined with chi-squared, multivariant regression analysis, and Student's t test with significance at p less than 0.05. RESULTS: Sixty-one (69%) patients had fasciotomy performed before 12 hours and twenty-seven (31%) after 12 hours. Although the rates of infection differed significantly between the two groups (7.3% for early versus 28% for late), the rates of limb salvage and neurologic sequelae were similar. Age, mechanism, shock, associated injuries, and time to fasciotomy were not predictive of complications. CONCLUSIONS: Fasciotomy for trauma is most efficacious when performed early. However, when performed late, it results in similar rates of limb salvage as compared with early fasciotomy but at the increased risk of infection. These results support aggressive use of fasciotomy in extremity trauma regardless of time of diagnosis.

[Treatment concept and results of grade 3 open fractures with arterial injuries requiring reconstruction]. / Behandlungskonzept und Ergebnisse von drittgradig offenen Frakturen mit rekonstruktionspflichtigen Arterienverletzungen.

Ninety-one open fractures associated with arterial injury requiring vascular repair (type IIIC injuries) were treated at the University of Louisville between May 1983 and January 1994. Involved anatomical areas were the humerus (6x), the forearm (11x), the femur (16x), the tibia (36x), the ankle (11x) and the foot (11x). Fracture management consisted of meticulous radical debridement, copious wound irrigation, fasciotomy and fracture stabilization. Additionally, 49 wounds (53.8%) were treated with the supplemental local use of antibiotics (tobramycin-PMMA-beads). Thirty-four patients underwent primary amputation whereas 57 repairs of the injured vessels were performed. There were 7 secondary amputations due to infection or poor revascularization resulting in an overall amputation rate of 45.1%. The wound infection rate was 12.1% (11/91) and the rate for osteomyelitis was 3.3% (3/91). The local use of the antibiotic beads was of significant benefit to lower infectious complications. Primary coverage of the soft tissue defect with free tissue transfer was associated with a high infection rate (2/3) and is not recommended for this type of injury. Temporary wound coverage with the "antibiotic bead pouch" technique until wound closure can be obtained in a sterile and viable environment leads to more satisfying results.

[Amputation injuries of large extremity segments. Clinical management]. / Amputationsverletzungen grosser Gliedmassenabschnitte. Klinisches Management.

Amputating injuries are often combined with multiple trauma. The management of these serious traumas has to consider survival more than restoration of function and extremity preservation. Out of 51 patients with 60 macroamputation injuries only one case was successful in replantation. The leading rule in the treatment of macroamputation still must be life before limb, as our series of the years 1988 up to 1991 clearly shows.

Population-based study of survival after osteoporotic fractures.

Vertebral fractures are the most frequent of the fractures associated with osteoporosis, yet little is known of their impact on health in the United States. To aid in this understanding, the authors examined the survival rate of 335 residents of Rochester, Minnesota, who had an initial radiologic diagnosis of vertebral fracture between 1985 and 1989. Seventy-six died during 809 person-years of follow-up. The overall survival rate was worse than expected, and diverged steadily from expected values throughout the course of the study. At 5 years after diagnosis, the estimated survival was 61% compared with an expected value of 76% (relative survival = 0.81, 95% confidence interval (CI) 0.70-0.92). The 5-year relative survival after a hip fracture in Rochester was a comparable 0.82 (95% CI 0.77-0.87), but there was a much greater excess of deaths within the first 6 months as compared with patients with vertebral fractures. The 5-year relative survival rate after a distal forearm fracture was 1.00 (95% CI 0.95-1.05). Clinically diagnosed vertebral fractures are rarely fatal, and the reduced survival seen subsequently could related to comorbid conditions. Nonetheless, the excess mortality should be accounted for in assessing the public health impact of osteoporosis.

Upper and lower limb fractures with concomitant arterial injury.

We describe a management strategy for upper- and lower-limb fractures with associated arterial injury and report the results in 113 cases treated over a period of 18 years. Primary amputation was performed in 23 patients and of those who underwent primary vascular repair, 27 needed secondary amputation, two-thirds of them within a week of the injury. Of those requiring secondary amputation, 51.8% had ischaemia exceeding six hours, 81.4% had severe soft-tissue injury and 85.2% had type III open fractures. The patients whose limbs had been salvaged were followed up for an average of 5.6 years. The eventual outcome depended on the severity of the fracture, the degree of soft-tissue damage, the length of the ischaemic period, the severity of neurological involvement, and the presence of associated major injuries. There was a 30% incidence of long-term disability in the salvaged limbs, largely due to poor recovery of neurological function. Prompt recognition of such combined injuries is vital and requires a high index of suspicion in patients with multiple injuries and with certain fracture patterns. We recommend a multidisciplinary approach, liberal use of pre-operative angiography in upper-limb injuries and selective use of intra-operative angiography in lower-limb injuries. Stable external or internal fixation of the fractures and re-establishment of limb perfusion are urgent surgical priorities to reduce the period of ischaemia which is critical for successful limb salvage.

Salvage of limbs with vascular trauma.

In an eight-year period we treated 51 cases of vascular injury associated with fractures and/or dislocations or soft-tissue injuries of the limbs. We relied on a clinical diagnosis and immediate exploration of blood vessels rather than the time-consuming procedure of arteriography. All patients were operated on by the orthopaedic residents on duty and not by vascular surgeons. Only 17 (33%) were repaired within six hours of injury. Limb viability with good function was obtained in 38. Complications included six deaths, four amputations, two renal failures and delayed occlusion in one case.